Federico Seragnoli on psychedelic-assisted psychotherapy in Swiss hospitals

At the Geneva University Hospitals psychedelic-assisted psychotherapy with LSD, psilocybin, and MDMA enhance therapy effects, or treating PTSD.

About the interview:

Federico Seragnoli is a psychologist and doctoral student at the University Hospital of Geneva (HUG). His work focuses on the therapeutic use of psychedelic substances. At the HUG, Swiss residents can now benefit from psychedelic-assisted psychotherapy (PAP) sessions. About 50 patients have already been treated. Switzerland is one of the few countries where three substances - LSD, psilocybin and MDMA - are applied  in compassionate use situations.

This interview was conducted by BenoĆ®t Blanquart and translated from the original French version.

Mr. Seragnoli, what is the role of psychedelic substances in psychotherapy?

The aim is to amplify the effects of psychotherapy. By temporarily changing the patient's perceptions, the psychedelic substances "open up" his or her representations. The patient thus has more psychological flexibility.

Addictions or anxiety are ways of avoiding one's own emotions, to preserve ourselves from them. With these substances, emotions are felt intensely, without escape. Confronted with their emotions, the patients can access traumatic memories and then modify certain automatisms. In addition, exchange and the therapeutic alliance between the patient and the therapist are increased.

Several studies have shown that psychedelic-assisted psychotherapy can alleviate anxiety or depressive symptoms, or reduce certain addictions. These substances do not act in the same way on the brain: psilocybin is mainly used to treat depression and LSD to treat anxiety.

What is the specific indication for MDMA?

In Switzerland, we use MDMA1 - also known as ecstasy - in the treatment of post-traumatic stress disorder (PTSD). This substance is in phase 3 development as a drug, so we use it for compassionate use. With the Food and Drug Administration (FDA) granting breakthrough therapy status2, we expect MDMA use for PTSD applications to be approved as early as 2024. The European Medicines Agency is expected to follow suit. This would make MDMA the first psychedelic substance to be officially considered as a medication.

PTSD is the result of a disturbance in the stress response of people who have experienced very difficult times. Because they are unable to 'metabolise' these events, their psyche has developed very strong defences. Often, patients no longer have access to their memories, even in therapy. Instead, they experience major biopsychological crises, with flashbacks, triggered by trivial events. These patients therefore live with a feeling of permanent threat. Some even experience episodes of depersonalisation.

By activating a nucleus of the amygdala, MDMA promotes the regulation of the stress response and thus allows access to traumatic memories during therapy. This seems to be more effective than EMDR [Eye Movement Desensitization and Reprocessing], the technique classically used for PTSD.

When used recreationally, MDMA provides an experience of being with others. In a therapeutic setting, it turns the patient towards himself. They can access their memories and express their rage and feelings of injustice.

What results can we expect from these psychedelic-assisted therapies?

As with conventional therapy, the intensity of the insight may vary [the process by which a subject grasps an aspect of his or her own psychic dynamics previously unknown to him or her]. But the experience is always interesting because patients learn about themselves.

We were able to verify the effectiveness of psychedelic-assisted psychotherapy (PAP) in alcohol withdrawal. One patient had been having crippling anxiety attacks five to six times a day for years. After the session, he had no attacks for a few days, then they returned but with less intensity. Sometimes the result is immediate and spectacular: one patient had been trying to stop smoking for 20 years and succeeded the day after the session.

Some patients don't feel the effects but we see that the session has still made a difference. In all cases, if there is no clear benefit, no further sessions are offered.

How do they work?

There are always one or two preparatory sessions, in which blood tests and an ECG are carried out. The usual treatments should be continued, except for triptans and anti-epileptics. For antidepressants, we assess the situation with the patient and if he or she agrees, their use is temporarily stopped.  

We then apply to the Federal Office of Public Health for a treatment permit. Each patient is entitled to three PAP sessions per year. However, the purchase of substances remains at the patient's expense.3

On the day the substance is taken, the care team is always present with the patient, but we only intervene at their request. It is only an introspective experience, there is no psychotherapy at that time. The patient lies in a safe bed, with a mask over their eyes and music if so wished. The session lasts between six and ten hours, depending on the substance.

An "integration" session takes place the next day, in the presence of the HUG therapists and possibly the therapist who usually follows the patient. The patient talks about his or her experience during the experiment. The interview is recorded so that the patient can listen to it again later, either alone or with their therapist. 

Finally, an "amplification" session takes place in our department four to six weeks later. We discuss the effects that the patient may have observed in his or her daily life as a result of the experience. This session is also an opportunity to discuss the next steps and, if necessary, to plan the next PAP session.

Are there any counter-indications?

In recreational contexts, psychedelics very rarely induce psychotic or manic states. All safety and supervision measures put in place in a therapeutic context prevent this risk. As a precautionary measure, a personal or family history of bipolar disorder or a psychotic episode is an absolute contraindication.

Otherwise, with the exception of severe and uncontrolled cardiovascular disease, seizure disorder or severe liver cirrhosis, there is no contraindication.

Are there any risks?

During the session, the psychotherapist may land in the position of a "guru" because the patient may project images of grandeur onto them. It is therefore necessary to be very vigilant on an ethical level.

In addition, slight and transient physical side effects may occur for a few hours after taking the substance. The dosages used are relatively low and do not present a risk of toxicity. There is also no risk of addiction.

We are very careful about the psychological side effects, which depend on the patient's psychological state at the time of the session. Psychedelic substances can cause anxiety or even a feeling of persecution, often immediately after taking them. This is why the session takes place in a very calm environment and in the presence of caregivers.

Beforehand, we decide with the patient how far to go in terms of physical contact during the session: putting a hand on their shoulder, taking their hand, etc. If necessary, we can soothe the patient with lorazepam or risperdone.

Outside the therapeutic context, other adverse effects are possible. They can occur when users mix several substances. But in the context of psychedelic-assisted psychotherapy, no serious side effects induced by these substances have ever been observed.

Notes and references
  1. MDMA (methylenedioxy-N-methylamphetamine) is a psychostimulant molecule of the amphetamine class.
  2. "Breakthrough therapy". Priority status granted by the US Food and Drug Administration to a drug product in the process of being validated and likely to provide a decisive therapeutic advance.
  3. The price depends on the dosage (1 Swiss franc or CHF equals to about 1 euro): 15mg psilocybin: 225 CHF / 25mg psilocybin: 375 CHF / 100mcg LSD: 128.40 CHF / 200mcg LSD: 256.80 CHF.